The national discussion about healthcare reform continues, especially as the Affordable Care Act’s health insurance marketplace coverage is set to take effect in January.

Healthcare reform is a heated topic, and there is plenty of confusion about what is fact and what is fiction. As we all talk about the future of healthcare, our discussion should be informed by facts.

With that in mind, here are four common myths — and the facts behind them.

Myth 1: The government is taking over health insurance

“As we all talk about the future of healthcare, our discussion should be informed by facts.”

David Longworth, MD

Chairman, Medicine Institute

Fact: Established private insurance companies sell plans on the new state and federal health insurance exchanges.

The rollout of Healthcare.gov does not represent a government takeover of insurance plans. The government provides the platform, but private insurers — including some of the biggest names in the industry — sell plans competitively through that platform. The Affordable Care Act (ACA) does increase government regulation of the insurance industry.

If you are selecting a plan on the health exchanges, be sure that your physician and hospital are included.

Myth 2: The government is seizing control of the care of patients

Fact: The healthcare system will still rely on a competitive market for delivery.

Will there be more government involvement in healthcare now, particularly in terms of quality measures? Yes. However, care is still provided at private hospitals, clinics and physician practices. Critics often compare the ACA to socialized systems such as England’s. Keep in mind that England’s medical professionals are employees of the government. That’s simply not the case in America, where private competition will remain the norm.

Myth 3: The government will ration care

Critics often tie the idea of rationing care to the Independent Payment Advisory Board (IPAB). The IPAB is a group that makes recommendations to the Secretary of Health and Human Services for reducing Medicare costs. However, by law, the IPAB does not write policy. It can only make recommendations — and Congress has the power to override those recommendations.

On top of that, the law’s language literally forbids the IPAB from making any recommendations that ration care, raise Medicare beneficiary premiums or restrict Medicare benefits.

Myth 4: The ACA provides free coverage to undocumented immigrants

Permanent legal residents can apply for subsidies on the health insurance marketplaces, just like American citizens can. But as with insurance plans, these subsidies are not available for illegal immigrants.

<nyt_text><nyt_correction_top>WASHINGTON — Four years after President Obama vowed to “dramatically reform the way we do business on contracts,” the spectacular failure of the HealthCare.gov website has renewed calls for changes in how the government hires and manages private technology companies.

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But despite Mr. Obama’s promises in the last two months to “leap into the 21st century,” there is little evidence that the administration is moving quickly to pursue an overhaul of the current system in the coming year.

Outside experts, members of Congress, technology executives and former government officials say the botched rollout of the Affordable Care Act’s website is the nearly inevitable result of a procurement process that stifles innovation and wastes taxpayer dollars. The Air Force last year scrapped a $1 billion supply management system. Officials abandoned a new F.B.I. system after spending $170 million on it. And a $438 million air traffic control systems update, a critical part of a $45 billion nationwide upgrade that is years behind schedule, is expected to go at least $270 million over budget.

Longstanding laws intended to prevent corruption and conflict of interest often saddle agencies with vendors selected by distant committees and contracts that stretch for years, even as technology changes rapidly. The rules frequently leave the government officials in charge of a project with little choice over their suppliers, little control over the project’s execution and almost no authority to terminate a contract that is failing.

“It may make sense if you are buying pencils or cleaning services,” said David Blumenthal, who during Mr. Obama’s first term led a federal office to promote the adoption of electronic health records. But it does not work “when you have these kinds of incredibly complex, data-driven, nationally important, performance-based procurements.”

The Standish Group, an information technology firm, deemed just 4.6 percent of large-scale government contracting projects executed in the past decade to be successful. More than half were “challenged,” and about 40 percent simply “failed.”

Multinational companies with large legal teams are often successful at winning years-long government contracts. But officials say technology innovation — particularly on web-based projects like the health care site — is often found in smaller firms, like many in Silicon Valley, that lack the size and the know-how to navigate the costly procurement maze.

“It’s a punishing and punitive environment to work in,” said Stan Z. Soloway, the chief executive of the Professional Services Council, a trade group, and a former Clinton administration official.

Officials said the administration was conducting a “review of options” for improving the government’s use of technology and was beginning to discuss the issue with stakeholders inside and outside government. But they declined to say whether Mr. Obama would call for changes in how Washington delivers technology projects during his State of the Union address early next year and whether the White House had any specific plan to make good on the president’s oft-stated interest in tackling the thorny, bureaucratic issue.

“This administration has made considerable progress in reforming federal I.T. management practices,” said Steven Posner, a spokesman for the White House budget office, citing new open-data and cloud-computing initiatives. “As the president made clear, significant challenges remain in the area of federal I.T., and we need to continue improving the way we deliver technology.”

In Mr. Obama’s first term, the administration pushed agencies to move away from expensive, dedicated hardware by adopting more flexible and cheaper Internet-based services when possible. Officials also began requiring agencies to replace proprietary data with modern open formats that can be easily understood by the public and the private sector.

But lawmakers and others said the Obama administration was doing too little to fix the fundamental problems, and they predicted that the issue would ultimately fall to Mr. Obama’s successor.

Representative Gerald E. Connolly, Democrat of Virginia, said the budget office, formally known as the Office of Management and Budget, refused to back bipartisan legislation that would consolidate responsibility for technology projects in a single person at each agency and increase the transparency of government spending on technology.

“O.M.B. takes the position, as it usually does, that we don’t need legislation to address these issues,” said Mr. Connolly, who represents a Washington suburb with hundreds of federal technology contractors. “O.M.B. was really our biggest stumbling block. It was maddening.”

Officials denied Mr. Connolly’s charge, saying the administration is open to legislation but has “some concerns” with the bill in the House because it does not apply to the Pentagon. A Senate version of Mr. Connolly’s legislation in the House was introduced last week by a Democrat and a Republican, but it also centers on the civilian agencies.

Aides pointed to the president’s recent comments about procurement as evidence that the administration is eager to confront the broader problem.

In an interview on MSNBC last month, Mr. Obama bemoaned systemic problems in big technology projects, saying that “our I.T. systems, how we purchase technology in the federal government, is cumbersome, complicated and outdated.”

He reiterated that thought in a news conference on Friday, and he has pledged to “refocus” on the issue during the rest of his term.

Last Tuesday, Mr. Obama met with 15 executives from some of the nation’s largest technology companies, including Tim Cook of Apple and Sheryl Sandberg of Facebook. Administration officials said the meeting was a first step in confronting the broader issue highlighted by the health care website debacle.

Technology experts across the political spectrum agree there are many problems to fix, from the White House down to the civil servants who administer the half-trillion dollars the government spends a year on procurement contracts, about 15 percent of its total budget.

“It’s not just the contracting rules,” Mr. Soloway said. “It’s the human capital, the way the government buys services, the way the government determines its own requirements, the lack of collaboration within government, the lack of collaboration between the government and the private sector, the outdated systems within government.”

Jim Johnson, the chairman of the Standish Group, said the government often required sweeping, singular contracts for projects that private businesses would complete for in pieces.

“It’s an iterative style,” Mr. Johnson said. “That’s how Google does it. That’s how eBay does it.” Mr. Johnson said the government’s successes tended to come from small, focused projects, which might attract more competitive bids. The success rate for small-scale government contracting projects in the past decade, according to his firm’s analysis, is nearly 55 percent.

The red tape also makes it difficult, if not impossible, for federal agencies to get the technology they need fast enough. “Agency leadership’s need for speed and agility has far outstripped the procurement and finance models,” Richard Spires, a former chief information officer of the Department of Homeland Security, told a congressional panel this year.

In addition, strict rules prevent the government from working closely with contractors once it has hired them. Dr. Blumenthal, the former Obama administration official, said the government system of managing technology projects was broken.

“I think there has to be some middle ground between the current straitjacket and the perfect process that allows any kind of vetting you might want to have,” said Dr. Blumenthal, who was responsible for distributing $30 billion in federal money to doctors and hospitals.

“I didn’t realize how much of a constraint or how disabling it was until I went to the private sector,” added Dr. Blumenthal, now the president of a foundation engaged in research on health and social policy issues.

Administration officials said they agreed with critics that the government needed to move away from an old-fashioned method of technology development that relies on a single, large vendor to develop technology in years-long contracts.

The United States spent 17.9% of the GDP on healthcare in 2012. Academic medicine, which makes up, approximately, 20% of these costs ($540 billion), is under profound threat. Teaching hospitals and medical schools are faced with declining clinical revenue, dwindling research dollars and increasing tuition costs. To meet these challenges, we believe academic medicine must embrace disruptive innovation in its core missions: educating the next generation of health professionals, offering comprehensive cutting-edge patient care, and leading biomedical and clinical research. Medical schools and academic health centers will need to significantly adapt in each of these areas in order to ensure the long-term health of the medical profession. The following are a few examples of disruptive innovations Tulane School of Medicine has embraced.

Medical information doubles roughly every five years, making it impossible for physicians to stay current. Computing power has also increased to the point that machines like IBM’s Watson, first programed to play chess and Jeopardy, are now used to diagnose and recommend treatment for patients. Mary Cummings, one of the first women aviators to land a plane on an aircraft carrier, faced a similar situation when she left the navy; a computer was replacing many of the skills she had acquired in order to fly. Today, as the Director of the Human and Automation Lab at MIT, she poses an important and related question: “Are we in Medicine teaching the next generation of physicians skills or are we teaching them expertise?” If we are teaching the former, then academic medicine faces obsolescence. However, if we emphasize the latter, our mission is durable. Skills equip people to respond to specific well-understood circumstances; expertiseprovides the capability to respond to highly complex, dynamic and uncertain environments.

At Tulane University School of Medicine, we believe that the focus of medical education should be on how we teach; because what we teach will be largely out of date by the time students finish their training. The expertise required for the next generation of physicians is to be lifelong learners, team players, educators and problem solvers. We teach expertise through an “inverted” learning model. Students are expected to have reviewed the subject material before class. During class-time the students work in small groups to solve problems and explain to their colleagues issues they did not understand. Master teachers are still needed to facilitate students’ synthesis of material in a collaborative discussion-oriented environment, but this structure has the advantage of allowing investment in the areas where hands-on teaching adds value while providing cost savings in the areas where it does not. The organization that is likely to play a major role in providing on-line medical education is the Kahn Academy under Dr. Rishi Desai. A newly established three and a half year program for medical students with PhDs in the biomedical sciences leverages these adult learning principles. This program shortens the time to get a degree and so reduces the cost of tuition.

Business models for patient care, a key source of revenue for medical schools, are also undergoing enormous change. Driven by the need to lower costs, and aided by new technologies, patient care is moving from the hospital to the outpatient setting and ultimately to wherever the patient happens to be located. For example, when the ACA (Affordable Care Act) is fully implemented in 2014 with a substantial increase in Medicaid recipients, the need for more primary care, as experienced in Massachusetts, will overwhelm the available capacity to provide such care.

One solution to this problem is moving the majority of primary and secondary healthcare delivery into the community. After Hurricane Katrina, Tulane partnered with a network of Federally Qualified Health Centers in order to provide services to low and middle-income patients in community-based clinics designated as medical homes. These not only provide less expensive care, but also provide the kind of experiential learning necessary to teach expertise to trainees. Expansion into telemedicine, which has been shown to reduce the cost of Medicaid in California and has had a dramatic impact in the United Kingdom on patients with diabetes, heart failure, and chronic obstructive pulmonary disease, will further reduce costs while improving the quality of care.

Yet another driver of disruption in academic medicine is the changing nature of how research is performed. It has been estimated that for every research grant dollar received by an academic health center, the institution must spend an additional 25 to 40 cents to support that research. Given declining clinical revenues and the relative flattening of the NIH budget, the ability to garner research funding is increasingly competitive and difficult to sustain. For most medical schools, this makes traditional research models inefficient and some institutions that have traditionally been primarily research focused will have to change their emphases.

An additional disruptive technology in research is using “big data,” large data sets that can be analyzed in distributed and cloud computing environments. In 2011, the 3-dimensional structure of a retrovirus protease was finally determined after eluding scientists for over a decade. The configuration was not discovered by a computer, by a single scientist or even by a group of scientists working in a laboratory. Rather, the structure was determined by a group of gamers working in the cloud with a program called Foldit that was developed by computer scientists at the University of Washington in only three weeks. The ability to collaborate without physical interaction using a variety of skill sets challenges the definition and funding models of research (not to mention who gets credit), but has vastly superior economies of scale.

Disruptive technologies threaten every mission of the academic health center. Examples from business have taught us that companies that survive disruption do so by being agile, experimental, problem driven and solution agnostic. Only through embracing coming and inevitable changes head-on rather than remaining entrenched in traditional structures, culture and processes, can academic health centers maintain their pre-eminence and viability. Building on inherent strengths while morphing to embrace change, disruptors can help ensure relevance and maintain competitive advantages.

Conflict in health care has dominated the news in the United States lately with the political showdown over the Affordable Care Act followed by the shaky launch of the federal health insurance exchange. Conflict, however, is not new to the health care system; it is a fragmented landscape with many players with sometimes conflicting interests and objectives. Yet the nuances of negotiation and conflict resolution are too rarely taught in medical or business schools.

We have been engaged in health care negotiation and conflict resolution for two decades. We have worked on conflicts as mundane as work assignments and as complex as hospital mergers. We use and teach a simple four-step structured process that works in cases ranging from simple one-on-one interactions to extended multi-party discussions.

After assembling representatives of all stakeholders in a conflict, the first step is to have each stakeholder articulate their “self-interests” so that they are heard by the others. What does each need to get from this exchange? The second step is to look at where the overlap among these self-interests reveals agreement, what we call the “enlarged interests.” In our experience, these agreements always outnumber the disagreements. The third step is to collaborate to develop solutions to the remaining disagreements, or “enlightened interests.” This is the time for creative problem solving. The fourth step is to certify what has now become a larger set of agreements, or “aligned interests.” Any outstanding disagreements are held to the side for future negotiations. We’ve taught people in as little as 30 minutes how to use this approach. (See our book Renegotiating Health Care for more detail on the process.)

We call this process the Walk in the Woods after a play that dramatized a well-known negotiation over nuclear arms reduction. The delegations from the United States and the Soviet Union were at loggerheads. During a break, the two lead negotiators went for a walk during which they unearthed their personal as well as each nation’s deeper, shared interests in peace and security. This understanding enabled them to break the deadlock and move forward.

The same negotiation principles that can reduce nuclear stockpiles can be effectively applied even at the front lines in health care. For example, there is often pressure to change who does what when new technologies are deployed or initiatives are undertaken to lower costs. Consider the situation in a traditional orthopedic practice where a physician sees every patient who comes through the door. Is this really best for the patient, the practice, and the larger system?

Most patients who arrive at an orthopedic office suffer from straightforward conditions such as a simple, non-displaced fracture or a sprain. These can be adequately treated by a properly trained physician’s assistant (PA), and patients can typically be seen much more quickly by a PA than by a specialist. If outcome quality and patient satisfaction can be maintained and costs lowered, this should be an easy move to make. Such shifts in responsibility, however, are often resisted and the resulting conflict can be acrimonious. Why?

Both physicians and patients have come to expect to interact with each other. Doctors prize their clinical autonomy and their relationships with those they treat, and the fee-for-service model rewards them for taking care of patients themselves. Patients, meanwhile, want to be treated by an “M.D.” and often a board-certified specialist rather than their primary care physician (PCP). The PCPs value their relationships with the specialists in the network and focus on their gatekeeper role rather than stretching the scope of care they provide. Insurers want to control costs, of course, and they and others exert pressure to divert simple cases from high-cost specialists to less expensive physician’s assistants or other non-specialist care-givers. No one is happy with the resulting conflict: Orthopods fear losing their patients; patients are anxious about getting lesser care; PCPs worry that their relationships with specialists will erode; and insurers and administrators find the resistance by all parties frustrating, time-consuming, and expensive.

Now, imagine that the physicians in our orthopedic practice host an open house Walk in the Woods discussion that includes referring PCPs, patients, and representatives from insurers. Engaging in the four-step process, the parties would find that high outcome quality, patient satisfaction, and keeping care affordable are on everyone’s list of self-interests. Through the process, the orthopedists could educate both the PCPs and patients on when a specialist’s expertise is truly needed. Patients could articulate how they weigh the trade-off between waiting time and the provider they would see. The insurers could explain some of the cost implications of different options. One can envision the idea of physician’s assistants treating routine injuries emerging from the process as each party identifies the benefits that meet their combined and self-interests: The orthopods may be freed up to see a greater number of more complex and interesting cases; the PAs are able to work to the level of their ability; the PCPs expand their relationships with more members of the orthopedic practice; the insurer reimburses less for uncomplicated treatments; and patients would get appropriate care, save time, and help keep premiums down.

The two aspects of this approach that can be extrapolated to myriad other conflicts are the use of a structured process and inclusion of all key decision-making stakeholders. The structured process minimizes the ego battles and tangential scuffles by keeping all parties focused on productively resolving the central issues. Depending on the number of parties and complexity of the negotiation a Walk can take from 10 minutes to 10 days or more.

The inclusion of all stakeholders is essential because people only truly embrace solutions that they help create. Anytime that one party tries to impose something on another, the natural inclination of the imposed upon party is to resist. A little time spent upfront engaging in joint problem solving saves many hours — and headaches — that come with a mandate.

Eric J. McNulty is the co-author of “Renegotiating Health Care: Resolving Conflict to Build Collaboration”. He is director of research and professional programs at the National Preparedness Leadership Initiative, a joint program of the Harvard School of Public Health and Harvard’s Kennedy School of Government.

ESCAPE FIRE exposes the perverse nature of American healthcare, contrasting the powerful forces opposing change with the compelling stories of pioneering leaders and the patients they seek to help. The film is about finding a way out. It’s about saving the health of a nation.